1. health and fitness
2. disease
3. cancer

85
Chapter
4
Mainly men
Angela Billington
CHAPTER CONTENTS
Introduction 85
Prevalence 86
Causes of LUTS in men 86
Assessing the problem 86
The urethra and pelvic floor 86
Postmicturition dribble 87
The prostate gland 87
Assessment of individuals with suspected prostate
disease 91
To screen or not to screen? 95
Transrectal ultrasound and biopsy 96
BPH and prostate cancer: treatment options 96
Treatment of BPH 97
Treatment of prostate cancer 100
Postprostatectomy incontinence 102
Managing incontinence 103
Conduction aids 104
Indwelling catheterisation 105
Intermittent self-catheterisation 108
Occlusive devices 108
Choice of product 108
Sexuality and LUTS 108
Conclusions 109
Ch004-F10347.indd 85
All we are, is the result of what we have thought.
The mind is everything. What we think . . . we
become.
Buddha (563–483 BC)
INTRODUCTION
There are limited data about the incidence, spontaneous remission rates and risk factors for urinary
incontinence (UI) in men. It is estimated that
between 2.5 and 4 million adults experience continence problems in the UK (Continence Foundation 2000). In almost all community-based studies
to date, the reported prevalence rates are less in
men than in women by a 1:2 ratio; however, after
the age of 65, prevalence rates are similar (Malmstein 1997, Stenzelius et al 2004). This said, the
issue of incontinence in the younger male population cannot and should not be ignored.
The type and age distribution are also different
between the sexes, and the risk factors, although
less investigated in men, seem to be different.
Incontinence should not be considered an isolated
problem in men, but rather as a component of a
multifactorial problem. These are often referred to
as LUTS (lower urinary tract symptoms) which
include storage symptoms such as frequency,
urgency and nocturia and voiding symptoms such
as poor flow, hesitancy, intermittent flow and terminal dribbling.
6/22/2007 10:41:42 AM
86
PROMOTING CONTINENCE
Whilst many of the causes of incontinence are
not specific to either sex and the principles of continence promotion and incontinence management
are generally common to both, the male urinary
tract and associated structures do present some
very specific issues of causality and management.
An increasing focus and interest in men’s health
should result in further research being undertaken
in this area. The potential impact of UI on the life
of an individual, male or female, should not be
underestimated and much can be done to assist
men who are experiencing continence problems.
This chapter builds upon the principles covered
throughout the book and focuses specifically
upon those aspects of care that are considered to
be ‘mostly pertinent to men’ – the causes of LUTS
and prostate disease.
CAUSES OF LUTS IN MEN
The most likely cause of LUTS is related to the
prostate. Symptoms can reflect either storage or
voiding problems. Storage problems may be due
to reduced capacity, which can be due to a small
capacity bladder, incomplete emptying due to
bladder outflow obstruction, increased detrusor
activity due to idiopathic causes, or irritative problems caused by urinary tract infection, obstruction
or bladder cancer. Outflow obstruction may be
due to benign prostatic hyperplasia or prostate
cancer, urethral or meatal obstruction, penile
cancer or detrusor failure due to neuropathy, or
may be drug induced with anticholinergics or
opioids.
ASSESSING THE PROBLEM
PREVALENCE
Prevalence of incontinence in men ranges from 3
to 39% depending on the population studied, the
definition of incontinence used and the survey
methods (Wilson et al 2005). A recent survey of
men in four different cities in France, England,
Korea and the Netherlands identified an incontinence prevalence rate in men over 65 years ranging
from 8% in Seoul to 23% in Birmingham (Boyle et
al 2003) but the authors suggest that cultural differences may contribute to the rates recorded. A
systematic review of 21 studies reported a prevalence of UI in older men ranging from 11 to 34%.
In the same review, the prevalence of daily UI in
men ranged from 2 to 11%. Studies that use a
broad definition of urinary incontinence, include
older and institutionalised men, and/or use selfreporting methods, tend to report higher prevalence (Thom 1998). For any definition of UI there
is an increase in prevalence with age.
Due to differences in pathological anatomy and
pathophysiology of urinary incontinence in men
and women, there is a different distribution in
incontinence subtypes. Hunskaar et al (2005) confirmed previous reports of the predominance of
urge incontinence (40–80%) in men, followed by
mixed forms of UI (10–30%) and stress incontinence (<10%). The increasing prevalence by age is
due to urge incontinence rather than stress.
Ch004-F10347.indd 86
Micturition does not conform to a standard pattern
and exhibits wide variation between individuals
(see Ch. 2). Few studies have examined voiding
patterns of healthy volunteers and further baseline data are needed for both males and females.
However, there appears to be little difference, at
least in frequency of voiding, between the sexes
(Denning 1996).
The urethra and pelvic floor
Males have an ‘S’-shaped urethra which is approximately 18–22 cm in length, compared to the
shorter, straight urethra in females (3–5 cm). This
factor is associated with a lower incidence of
urinary tract infections (UTIs) in men compared to
women. UTIs are, in turn, frequently cited as
causes or risk factors for transient urinary incontinence by increasing sensory input from the
bladder and contributing to urgency and detrusor
instability. UTI may also exacerbate other types of
bladder dysfunction. However, whilst the length
and shape of the male urethra may have a protective function with regard to infection, these characteristics can contribute to other problems such
as the ‘postmicturition dribble’ experienced by
many men and discussed later in the chapter.
Stress incontinence results primarily from a
failure of the external urethral sphincter to accom-
6/22/2007 10:41:42 AM
Mainly men
modate increases in intra-abdominal pressure.
The external (voluntary) sphincter is formed by
the pelvic floor muscles; any factor contributing to
a reduction in the strength of these muscles or in
the patency of the seal formed by the urethra is
therefore likely to predispose an individual to
stress incontinence (see Chs 2 and 3). In fact,
genuine stress incontinence is rare in neurologically normal males, although it may result
from prostate surgery or chronic retention (RCP
1995).
Postmicturition dribble
Postmicturition dribble (PMD) describes the loss
of a small amount of urine after voiding is completed. It is unique to men and is a common and
annoying condition in later life and one which can
affect quality of life. It can be an important factor
in motivating men to consult their doctor. Milliard
(1989) suggested that postmicturition dribble that
is not associated with obstruction might be caused
through the urethra being emptied incompletely
by the muscles surrounding it. Denning (1996)
suggests that it is caused by pooling of urine in the
bulbar urethra which for some reason is abnormally lax and wide. Pelvic floor exercises or bulbar
urethral massage are recommended as treatment
for this annoying but benign problem. This technique is sometimes referred to as ‘milking the
urethra’ and involves putting the ball of the thumb
behind the testicles and pushing up and forward
to exert pressure on the urethra, causing the urine
to be expelled.
The prostate gland
The healthy prostate is a small gland about the
size of a walnut lying just below the bladder. It
forms part of the male reproductive system, is
attached to the base of the bladder and surrounds
the initial 3–4 cm of the urethra; the urethra passes
through the centre of the gland to the penis. The
main function of the prostate is to make a lubricant as part of the seminal fluid. It is suggested
that the prostate acts a bit like a ‘junction box’ in
that it allows the ducts that transport sperm from
each testicle and the ducts that drain from the
Ch004-F10347.indd 87
87
Bladder
Prostatic
urethra
Prostate
Ejaculatory duct
openings
External urethral
sphincter
a. Normal prostate
Verumontanum
Ejaculatory
duct
Urethra
b. Frontal view
Peripheral
zone
c. Sagittal view
Transition
zone
Central
zone
Figure 4.1 Anatomy and morphology of the prostate.
Reproduced with permission from Kirby & McConnell
(2004).
seminal vesicles to meet and then empty their contents into the urethra during ejaculation.
The prostate gland is divided into two morphologically distinct zones, central and peripheral,
that comprise 25% and 70% of the normal prostatic
volume respectively. The remaining 5% of the
normal gland consists of the transition zone which
lies adjacent to the urethra and extends up to the
bladder neck (Fig. 4.1). Although the histological
characteristics of the transition zone and the
peripheral zone are similar, the transition zone is
the site of development of benign prostatic hyperplasia, while the adjacent peripheral zone is the
more usual site of prostate cancer (Kirby et al
1994).
Three main diseases of the prostate can affect
urinary continence:
6/22/2007 10:41:42 AM
88
PROMOTING CONTINENCE
Ch004-F10347.indd 88
a hesitant, interrupted, weak stream of urine
straining to void.
Irritative voiding symptoms:
●
●
urgency and urge incontinence
frequency of urination, especially at night.
As the population ages it seems inevitable that the
number of men presenting with BPH will increase.
Prostate assessment clinics are a response to this
perceived trend. The clinics aim to reduce waiting
times, lead to prompt referral of those with severe
symptoms and to provide better continuity and
quality of care (Webb & Simpson 1997).
Prostate cancer
Prostate cancer is the most commonly diagnosed
cancer in men in the UK, accounting for almost
one in four of new male cancers diagnosed (Cancer
Research UK 2006) and 14% of male deaths from
cancer. This represents the second most common
cause of male deaths from cancer after lung cancer
(Figs 4.2 and 4.3).
100
Incidence
Mortality
75
50
25
2004
2001
1998
1995
1992
0
1989
Limits fluid intake before travel
Restricts fluid intake before bedtime
Cannot drive for 2 hours without a break
Disruption of sleep
Limits going to places without toilets
Limits playing outdoor sports
Limits participation in social activities, e.g. going
to the cinema, theatre or church
●
1986
•
•
•
•
•
•
•
●
1983
Box 4.1 Adverse effects of symptoms of
BPH on activities of daily living
Obstructive symptoms:
1980
Benign prostatic hyperplasia (BPH) is by far the
most common disease of the prostate: 80% of presenting cases, compared with 18% prostate cancer
and 2% prostatitis (Kirby et al 1994). BPH increases
with age and this may reflect an age-related hormonal imbalance between testosterone and oestrogen. Classic autopsy studies (Ball et al 1981)
have shown that histological BPH appears to rise
to 50% in men in their 60s and to 90% in men over
80 years of age; however, the proportion of men
with palpable prostatic enlargement or symptoms
is less, with a prevalence of 21% in men aged 50
and 60 years, rising to 53% in men in their 80s. A
population study from Stirling, UK (Garroway &
Collins 1991), also reported a prevalence of symptomatic BPH of 43% in men over 60. BPH is one of
the most common diseases to affect men beyond
middle age and is now so common among older
men that its absence could be regarded as abnormal (Webb & Simpson 1997). About half of the
men with evidence of BPH (more than 20 g, symptoms of LUTS and a peak flow less than 15 ml/s)
reported interference with one or more activities
of daily living (Box 4.1).
BPH is rarely a life-threatening condition when
appropriately assessed and managed. Deterioration in symptoms and urinary flow is usually
slow, and serious outcomes, such as renal insufficiency, are uncommon. The incidence of acute
retention increases with prostate size and requires
1977
Benign prostatic hyperplasia
1974
●
urgent treatment. The relatively less serious symptoms of frequency, nocturia and incomplete emptying can nevertheless be very bothersome and
may substantially impact on the patient’s quality
of life. In addition, men with LUTS due to BPH
are also prone to erectile dysfunction and disorders of ejaculation (Dorey 2001a). The symptoms
of BPH can vary but the typical ones are:
1971
●
benign prostatic hyperplasia
prostate cancer
prostatitis.
Rate per 100,000 population
●
Year of registration/death
Figure 4.2 Incidence and mortality rates for prostate
cancer. Reproduced from Cancer Research UK (2006).
6/22/2007 10:41:42 AM
Mainly men
USA
Sweden
Canada
Switzerland
Australia
France
Netherlands
Brazil
UK
Italy
Denmark
Zimbabwe
Singapore
Japan
India
China
Table 4.1 Gleason grading system
Incidence
Grade
Histological characteristics
Probability of
local progression
over 10 years (%)
1–4
5–7
Well differentiated cancer
Moderately differentiated
cancer
Poorly differentiated cancer
25
50
8–10
75
Mortality
0
20
40
60
80
100
120
140
Rate per 100,000 males
Figure 4.3 Incidence and mortality rates, prostate
cancer in selected countries. Reproduced from Cancer
Research UK (2006).
Ethnic variations appear to exist and death rates
are raised in Caribbean and West African men. In
terms of prevalence, prostate cancer shows a
similar pattern to BPH, in that it is generally a
disease of older men and is rare in the under-50
age group. By the age of 80 about half of all men
will have a focus of cancer in their prostate,
although only 1 in 25 males will actually die from
it (DH 2000a).
Treatments for prostate cancer can lead to the
unwanted side effect of urinary incontinence.
Indeed continence may be the second ‘big C’ they
must confront as they begin to cope with the
impact of the cancer treatment. Although bladder
disturbance can be temporary, patients view their
incontinence as disabling with a negative effect on
their quality of life (Butler et al 2001).
The stage and grade of prostate cancer There
are a number of ways to treat prostate cancer
depending upon how far the disease has spread.
There are four basic stages: by convention the
letters ‘TNM system’ (tumour, node, metastases)
is used as a prefix for the stage of the cancer (i.e.
T1, T2, T3, T4). Staging is extremely important in
the decision-making process; if the cancer has
spread beyond the prostate margins surgery will
not be curative (Fig. 4.4).
Ch004-F10347.indd 89
89
To help decide whether the cancer is likely to
progress quickly the tumour grade is scored using
a graded scale invented by Dr Donald Gleason.
This system assigns a grade ranging from 1 to 5
based on the arrangement of the cancer cells in
relation to normal prostate cells. If the cancer cell
cluster resembles the small, regular, evenly spaced
glands of normal prostate tissue, a Gleason grade
of 1 is assigned. If the cancer cells lack these features and seem to spread haphazardly, it is a grade
5. Because prostate cancers often have areas with
different grades, primary and secondary grades
are given to the two areas that make up the most
cancer. The Gleason score is therefore made up of
the two grades (e.g. 3 + 2 = 5); the higher the score
out of 10, the more likely that the cancer will grow
and spread rapidly (Table 4.1).
In view of the non-specific nature of prostatic
symptoms, careful diagnosis is important. There
are three recognised methods of distinguishing
prostate cancer from BPH: prostate-specific antigen
(PSA), digital rectal examination and transrectal
needle biopsy. The cause of prostate cancer is
unknown. However, several risk factors have been
identified:
●
●
●
Having relatives who have had cancer of the
prostate
Belonging to certain ethnic groups (African–
Caribbean/African–American)
Eating a diet high in animal fat and protein (DH
2000a).
The symptoms of BPH and prostate cancer are
often similar and the majority of men with these
symptoms have benign disease. However, some
individuals who have cancer are asymptomatic
and, for some, symptoms occur only at the late
6/22/2007 10:41:43 AM
90
PROMOTING CONTINENCE
T1
T2
T3
T4
Figure 4.4 Local staging of prostate cancer. The tumour may advance from T1 to T4 with or without the
development of metastases. Reproduced with permission from Kirby & McConnell (2004).
stages of the disease. Clearly early diagnosis is
important and will be discussed later.
Prostatitis
The prostate is spongy and contains innumerable
channels and ducts, which can be prone to infection. If an obstruction such as a urethral stricture
Ch004-F10347.indd 90
occurs distal to the prostate, infected urine maybe
forced into the prostatic ducts and cause prostatitis. Acute prostatitis can occur without warning
with a systemic illness marked by rigors, fever and
muscular pain. Clinically, the patient is very
uncomfortable and feels aching in the perineum,
which radiates to the thighs and penis. Passing
urine is painful and the stream may be thin, with
6/22/2007 10:41:43 AM
Mainly men
Box 4.2 Common symptoms of acute
prostatitis
Box 4.3 Prostate assessment procedure
performed by specialist nurse
• Penile, pelvic or rectal pain, often felt deep
between the legs, which is worse on sitting
• Frequency or discomfort on passing urine
• Pain on or after ejaculation
• Quick (premature ejaculation), delayed (retarded
ejaculation) or unsatisfactory ejaculation
• Rarely, blood in semen (haemospermia), more
likely if infection present
• The patient is asked to attend with a full bladder
and to bring an early morning specimen of urine
• Patient history should include any relevant
medical or surgical history, lower urinary tract
symptoms and contributory factors such as
constipation, fluid intake and drug therapy
• International Prostate Symptom Score (I-PSS)
• Urinary flow measurement (preferably two)
• Postvoid residual
• Urinalysis for leucocytes, nitrites and/or blood
• Digital rectal examination
• Blood tests for prostate specific antigen (PSA),
urea and creatinine
• Frequency/volume chart
symptoms of frequency and often a high fever
(Box 4.2). Palpation reveals a tender, swollen prostate and the urine may or may not grow pathogens
on culture. If organisms are identified they should
be treated with either a fluoroquinolone or a sulfabased antibiotic such as trimethoprim that can
penetrate the prostatic tissue in adequate quantities. Treatment must be given for 6 weeks for acute
flare-ups and 12 weeks for those patients who are
chronically symptomatic. Prophylactic or suppressive antibiotics plus prostatic massage may be
required in refractory, relapsing or recurrent
disease. Surgery, except as definitive therapy for
a lower urinary tract problem (e.g. bladder neck
stenosis or urethral stricture), should be considered only as a last resort (Kirby R 1997).
ASSESSMENT OF INDIVIDUALS WITH
SUSPECTED PROSTATE DISEASE
Urinary incontinence is an embarrassing and
unpleasant complaint which many people hide
from their families, friends and indeed healthcare
professionals. Men seem to be particularly reluctant to seek help, often seeing incontinence as a
‘woman’s problem’ (Hunskaar & Sandvik 1993).
Most men with incontinence or evidence of urinary
tract outflow symptoms can be managed in
primary care. The outcome is likely to be improved
if the patient and healthcare professional decide
on treatment in partnership, with promotion of
self-management (NICE 2000). It is widely accepted
that general screening for prostate disease is not
practicable but opportunistic questioning can play
a vital role in identifying cases of prostatic disease.
There are three essential questions:
Ch004-F10347.indd 91
●
●
●
91
Are you bothered by your bladder symptoms?
Do you get up at night to urinate more than
twice?
Have you recognised a change in your urinary
flow?
Further investigation should be offered if the
patient answers yes to more than one of these
questions (Billington 1999). Completing the International Prostate Symptom Score (I-PSS) (Barry et
al 1992), one of several validated tools used to
assess the severity of an individual’s symptoms
(Fig. 4.5), and a full prostatic assessment (Box 4.3)
(Billington 1999) provide a qualitative and quantitative assessment of the impact and extent of
prostatic symptoms.
Investigations should include the following.
International Prostate Symptom Score (I-PSS)
The I-PSS is used to check the ‘bother’ factor for
the patient. A score of less than 7 indicates mild
symptoms, 8–19 moderate symptoms, and more
than 18, severe symptoms. Those with a symptom
score of more than 19 should be referred for further
medical advice. Any assessment should include
reference to the impact that the individual’s prostate problem is having on their life in general.
Although the single question shown in Figure 4.5
will not capture the total impact of symptoms on
6/22/2007 10:41:43 AM
Ch004-F10347.indd 92
0
0
None
Weak stream
Over the past month how often have you had a weak urinary stream?
Straining
Over the past month, how often have you had to push or strain to
begin urination?
5.
6.
1
1
1
1
2
2 times
2
2
2
2
2
2
3
3 times
3
3
3
3
3
3
Less than About half
half the
the time
time
4
4 times
4
4
4
4
4
4
More than
half the
time
5
5 times
or more
5
5
5
5
5
5
Almost
always
Your
score
1
Pleased
2
Mostly
satisfied
3
Mixed – about
equally satisfied
and dissatisfied
4
Most
dissatisfied
unhappy
5
Terrible
20–35 = severely symptomatic
Figure 4.5 International Prostate Symptom Score (I-PSS). Reproduced with permission from Barry et al (1992).
0
Delighted
8–19 = moderately symptomatic
If you were to spend the rest of your life with your urinary condition
just the way it is now, how would you feel about that?
Quality of life due to urinary
symptoms
1–7 = mildly symptomatic
The total score can range from 0–35 (asymptomatic to very symptomatic). Although there are at present no standard recommendations on grading patients with mild,
moderate or severe symptoms, patients can be tentatively classified as follows:
Total I-PSS score
0
1 time
0
Urgency
Over the past month how often have you found it difficult to
postpone urination?
4.
7. Nocturia
Over the past month, how many times did you most typically get up
to urinate from the time you went to bed at night until the time you
got up in the morning?
1
0
Intermittency
Over the past month how often have you found you stopped and
started again several times when you urinate?
3.
1
0
Frequency
Over the past month how often have you had to urinate again less
than 2 hours after you finished urinating?
2.
1
Less than
one time
in five
Incomplete emptying
Over the past month how often have you had the sensation of not
emptying your bladder completely after you finish urinating?
0
Not
at all
1.
Date
Patient Name
92
PROMOTING CONTINENCE
6/22/2007 10:41:43 AM
Mainly men
quality of life, it may serve as a valuable starting
point on which to base further conversation
between the practitioner and the patient.
exclude BPH. It may be useful as a safety measure
in monitoring the progress of patients who opt for
watchful waiting.
Frequency/volume chart
Urinalysis
This provides an indication of fluid intake patterns, type of fluid drunk, functional bladder
capacity, frequency and the presence and degree
of nocturia experienced (see Ch. 2).
Urinalysis, either by dipstick or by microscopic
examination of sediment, should be performed in
all men presenting with LUTS. Urinalysis helps to
distinguish BPH from urinary tract infection
or bladder cancer, which may produce similar
symptoms. If urinalysis is positive, urine microscopy and culture should be carried out and further
imaging and evaluation of the renal tract considered. Urine cytology should be requested in those
with severely irritative symptoms or haematuria
to exclude carcinoma in situ of the bladder. If
urine cytology is positive, renal ultrasound and
lower tract endoscopy and biopsy are mandatory;
CT scan is optional (Kirby & McConnell 2004).
Uroflowmetry
Uroflowmetry provides a simple means of quantifying the degree of outflow obstruction. Electronic measurement of urine flow rates is an
extremely useful, non-invasive test in most patients
with BPH (Fig. 4.6) and is helpful in identifying
patients whose peak flow rate is not diminished
and thus unlikely to benefit from surgery. Such
patients are more likely to be complaining of an
overactive bladder rather than BPH. Uroflowmetry measures a number of parameters of obstruction, of which the most important is the peak flow
rate. A peak flow rate below 15 ml/s (with voided
volume of at least 150 ml) suggests obstruction
(Kirby & McConnell 2004) although in older men
(70–80 years of age) values of 10 and 15 ml/s may
be normal. The presence of a markedly reduced
peak flow rate (<10 ml/s) usually indicates some
degree of obstruction which is most often caused
by BPH. Uroflowmetry is an inadequate test to
assess obstruction versus impaired detrusor function as the cause of a low flow rate and is prone
to artefact if the bladder volume is less than
150 ml.
Postvoid residual (PVR)
PVR is measured by transabdominal ultrasound
and is a useful optional test in the evaluation of
BPH, especially in combination with uroflowmetry, as it can help separate patients who are likely
to respond to watchful waiting or medical therapy
from those who may not. In general, PVR values
above 200–300 ml usually indicate a higher likelihood of medical therapy failing, and probably also
indicate a higher risk of acute urinary retention
(AUR). The test cannot be used to confirm or
Ch004-F10347.indd 93
93
Digital rectal examination
Digital rectal examination (DRE) should be performed on all men with LUTS. Although the prostate is readily palpated by DRE, in its early stages
prostate cancer is seldom detectable. DRE is
usually performed by the patient’s GP, but nurse
specialists may also conduct DRE. The test provides vital information regarding size of the prostate, consistency and anatomical limits. A normal
prostate feels smooth, about the size of a walnut,
with the lateral and cranial borders and medial
sulcus of the prostate being identifiable; the
seminal vesicles should be impalpable. An
enlarged prostate is indicative of BPH, whereas a
hardened, nodular prostate, or an immobile prostate, is suggestive of cancer. The examination may
feel uncomfortable but tenderness upon examination is an indication of prostatitis (Table 4.2). The
examination also allows the nurse to assess rectal
muscle strength and skin health in the perianal
area. Overall, DRE in isolation is less than 50%
accurate in detecting prostate cancer and is usually
done in conjunction with PSA (DH 2000a).
Blood tests
Blood tests should be performed for renal function
and to measure PSA, a protein produced by the
6/22/2007 10:41:43 AM
94
PROMOTING CONTINENCE
a
20
Flow rate ml/s
15
Normal
Parameter
Normal
BPH
BPH
Voiding time
17 seconds
79 seconds
Flow time
17 seconds
73 seconds
Time to maximum flow
7 seconds
9 seconds
Maximum flow rate
19.6 ml/s
13.3 ml/s
Average flow rate
12.1 ml/s
6.0 ml/s
Voided volume
406 ml
246 ml
10
5
0
0
10
20
30
40
50
60
70
80
Time (seconds)
b
Figure 4.6 Uroflowmetry using a flowmeter (a) measures a number of parameters of obstruction (b) that are usually
altered in patients with BPH. (b) Reproduced with permission from Kirby & McConnell (2004).
prostate. Creatinine and electrolyte levels are
measured to check renal function, as some 10% of
patients with BPH who have seen a urologist have
some renal impairment (Kirby M 1997). Prostate
enlargement tends to cause an increase in the level
Ch004-F10347.indd 94
of the PSA, with malignant tumours producing a
greater increase than benign enlargement.
However, other conditions can also cause PSA to
rise, such as a UTI and prostatitis. Although serum
PSA testing has fundamentally transformed the
6/22/2007 10:41:43 AM
Mainly men
Table 4.2 Assessment through digital rectal
examination
Characteristic
Appearance
Size
The normal prostate gland is the size of
a walnut; enlargement occurs in
both BPH and prostate cancer
A normal prostate is smooth or elastic
The lateral lobes are symmetric and
divided by a palpable sulcus
A tender prostate may indicate
prostatitis
A hard nodular prostate may indicate
prostate cancer
A malignant prostate gland may be
fixed to adjacent structures
Consistency
Mobility
diagnosis and treatment of prostate cancer, the
ability of PSA to correctly discern cancer from
benign disease is imperfect. This has prompted
efforts to improve the diagnostic capability of PSA
assays. Produced by epithelial cells and secreted
into the prostatic ducts, PSA is a serine protease
that may enter the systemic blood circulation
where it exists in several forms that are classified
into two broad categories: unbound or ‘free’ forms
(fPSA) and bound or ‘complexed’ forms (cPSA).
Three different PSA assays are commercially
available and applicable to clinical urology: tPSA,
fPSA and cPSA. The oldest, most ubiquitous assay
is the tPSA assay, which measures all immunoreactive forms of PSA, free and complexed, present
in serum, i.e. total PSA. The tPSA assay is sensitive
for prostate cancer detection but suffers from low
specificity. Low specificity increases the number
of unnecessary biopsies, and it is this diagnostic
shortcoming that newer assays have sought to
rectify. The fPSA assay provides the percentage of
free PSA (%fPSA, the ratio of fPSA to tPSA) which
has greater specificity than tPSA for prostate
cancer. When applied properly, fPSA may reduce
unnecessary biopsies on 20% of men with tPSA in
the 4–10 ng/ml range (Catalona et al 1998).
The cPSA assay was also developed to improve
specificity. The rationale for cPSA testing is that
the proportion of cPSA is greater in men with
prostate cancer (Kellogg Parsons & Partin 2004).
Ch004-F10347.indd 95
95
cPSA is a versatile assay applicable to population
screening and diagnosis, and to prediction of
pathological stage and longitudinal serum monitoring in patients with prostate cancer. For detection of cancer, cPSA is significantly more specific
than tPSA at all clinically relevant sensitivities, is
as specific as %fPSA and is less costly. Kellogg
Parsons and Partin recommend that cPSA is used
as the initial diagnostic test for prostate cancer
with a preliminary recommended threshold of
3.2 ng/ml or greater for biopsy. They also recommend that cPSA could be used in staging nomograms and longitudinal evaluation of patients
with prostate cancer. This would have the benefit
of reducing the number of unnecessary biopsies,
diminish screening costs and potentially minimise
the confusion associated with multiple serum
assays. Therefore, although a slight elevation in
the PSA may indicate prostate cancer, it is by no
means definite; approximately two out of three
men with a raised PSA will not have prostate
cancer. The advantage of PSA testing is that it can
find cancer before symptoms develop and may
detect cancer at an early stage when treatment
could be beneficial. The downside is that it can
miss cancer and provide false reassurance; alternately, false positives may cause unnecessary
anxiety and medical tests when no cancer is
present. It may detect slow-growing cancer that
may never cause any symptoms or shorten
lifespan. The PSA debate is a complex one.
To screen or not to screen?
Although there is pressure to introduce prostate
cancer screening within the UK, the view of the
National Screening Committee (2000a,b) is that
there is currently no high-quality evidence that
screening reduces mortality and that present
knowledge about prostate cancer does not conform
to the majority of the 10 principles that should
govern a national screening programme, proposed
by the World Health Organization in 1968. Yet
screening is recommended in other countries, particularly the USA. Men or their partners obtain
information about PSA from websites and may
request or even demand testing. Further ethical
issues surround those correctly identified as
having prostate cancer as it is often impossible to
6/22/2007 10:41:44 AM
96
PROMOTING CONTINENCE
distinguish between slow-growing tumours that
cause no harm and fast-growing tumours that kill
(DH 2000a). If screening were to be introduced,
some men with low-grade prostate cancer might
be subjected to traumatic treatment with the
unpleasant side effects of erectile dysfunction and
incontinence, who might never have suffered any
ill effects from prostate cancer in their lifetime.
The National Institute for Health and Clinical
Excellence (NICE) is due to report on Prostate
Cancer: Diagnosis and Treatment in November
2007.
For those men concerned about the possibility
of prostate cancer, the PSA test is still available.
However, clear information about the benefits and
risks of testing should be provided to men to
ensure that they are fully informed of the reliability of the test before giving consent. The impetus
for improvement in this area of care comes from
the Prostate Cancer Risk Management Programme
(http:/www.cancerscreening.nhs.uk/prostate)
which provides information packs for GPs and for
patients, with guidance on understanding the PSA
test, and through the National Prostate Cancer
Programme which funds an extensive programme
of research on all aspects of prostate cancer diagnosis and treatment (DH 2000a). At present, prostate screening is not recommended for routine use,
based on evidence provided in two systematic
reviews of the literature (Chamberlain et al 1997,
Selley et al 1997). Further work is being funded in
this area, but this does not affect the clinical management of men with symptoms of prostate
cancer.
European Randomised Study of Screening for
Prostate Cancer (ERSPC)
The ERSPC study is currently the largest randomised controlled trial of prostate cancer screening. It aims to determine whether the effect of
early detection and treatment of prostate cancer
will reduce deaths from prostate cancer. There are
eight participating centres: the Netherlands,
Sweden, Finland, Belgium, Italy, Portugal, Spain
and Switzerland. Recruitment to the study is still
underway and the target is to recruit 180 000 men
in total. Each man will be chosen at random to
either be screened for prostate cancer (using the
Ch004-F10347.indd 96
PSA test with or without DRE) or join a control
group which will not be screened. The first results
from the study are expected before 2010.
Transrectal ultrasound and biopsy
When DRE and/or PSA abnormalities are present,
transrectal ultrasound (TRUS) provides the most
convenient and accurate way of obtaining prostatic biopsies. An automatic biopsy needle is
advanced transrectally under ultrasound control
and sextant prostate biopsies are taken. With adequate antibiotic cover (typically ciprofloxacin
within 24 h of the biopsy), morbidity of TRUS
biopsy is minimal and infectious complications
occur in approximately 2% (Desmond et al 1993).
Clearly other causes of urinary symptoms (e.g.
infection, overactive bladder or stress incontinence) need to be excluded and a comprehensive
baseline assessment in keeping with that currently
recommended by the Department of Health
(2000a) applies equally to those presenting with
prostate symptoms. However, when an individual
presents with acute urinary retention its immediate relief is an urgent priority if backpressure on
the kidneys is to be prevented. Having decided on
the diagnosis, treatment options need to be
explored.
BPH and prostate cancer:
treatment options
The treatment of BPH and prostate cancer do have
some similarities, but also marked differences.
They are therefore considered separately for ease
of discussion. The main treatment options are discussed within this section. For a more comprehensive and detailed account, the reader is referred to
more specialist texts.
In males with BPH, if there is no urgent reason
to refer, a period of conservative treatment of 3
months is recommended (Abrams 1997, Feneley et
al 1999). If the patient has mild to moderate
obstructive symptoms, medical management with
alpha-blockers and/or 5-alpha reductase inhibitors is generally the first approach. For those with
irritative voiding symptoms, bladder training,
advice on fluid intake, pelvic floor exercises, plus
or minus an anticholinergic drug if the patient is
6/22/2007 10:41:44 AM
Mainly men
thought to have detrusor instability, may also
assist. It is not uncommon for some men to experience a year or more during which their prostate
irritates them, only for symptoms to get better
without any treatment (Blandy 1998).
Men can be taught how to carry out pelvic floor
exercises in the same way as women (see following radical prostatectomy later in the chapter for
further details), but have the added advantage
that by practising in front of a mirror they can
observe muscle contraction at the base of the penis
and a scrotal lift. They can also learn to palpate
muscle contraction at the perineum 2 cm medially
and 2 cm anteriorly to the ischial tuberosity (Dorey
2001b). This is useful when teaching and learning
the correct technique but the frequency and intensity of the exercise regime are determined by
individual assessment and DRE. Although it is
common practice to recommend that men practise
pelvic floor muscle training (PFMT) prior to
transurethral resection of the prostate (TURP),
there are no substantive data to support this
practice.
Medical management of BPH has revolutionised the care that men are now receiving and consists primarily of alpha-blockers and/or 5-alpha
reductase inhibitors. Surgery has become the
secondary rather than the primary treatment for
those with mild symptoms. Surgery as the first
choice is still indicated for men who are experiencing persistent, moderate or severe symptoms or
who have had acute urinary retention. Surgical
prostate ablation, by TURP or less frequently open
prostatectomy, is still the ‘gold standard’ and produces the greatest measurable and long-term
reduction in both symptoms and bladder outlet
obstruction (Feneley et al 1999). Other methods of
ablation (e.g. laser techniques) are newer and evidence of their efficacy is currently limited.
Treatment of BPH
As suggested earlier, conservative treatment or
‘watchful waiting’ is the preferred option for men
with mild symptoms as disease progression is
uncertain and often slow (Billington 1999). If the
patient wishes to try drug therapy an alphablocker (e.g. prazosin, indoramin) is usually the
treatment of first choice for BPH, since its effects,
Ch004-F10347.indd 97
97
if any, are immediate (Feneley et al 1999). These
drugs improve both filling and voiding symptoms
in BPH by relaxing smooth muscle and reducing
urethral resistance. Caution is advised in the treatment of older men or those on antihypertensives
using this method. However, some drugs are now
said to be more urospecific or selective and therefore to have fewer side effects (e.g. alfuzosin).
Nonetheless, patients using these drugs should be
advised of potential side effects such as postural
hypotension and dizziness.
The use of 5-alpha reductase inhibitors to
shrink the epithelial part of the gland is another
option. The action of drugs such as finasteride is
to reduce the size of the prostate by suppressing
plasma levels of dihydrotestosterone (DHT), the
principal agent causing prostatic enlargement.
However, it is suggested that these drugs benefit
only a minority of men, with maximum effect
taking at least 6 months to be achieved (Feneley et
al 1999). Men receiving alpha reductase inhibitors
need to be warned of potential side effects such as
erectile dysfunction, reduced ejaculate volume
and loss of libido (Billington 1999) (Tables 4.3
and 4.4).
Surgical treatment of BPH most commonly
involves transurethral resection of the prostate.
An instrument is passed along the urethra to the
prostate gland and the enlarged prostate is ‘pared’
away from inside the urethra (Fig. 4.7). The process
can easily be visualised if you imagine the coring
of an apple. The aim of this technique is to relieve
the obstruction at the bladder neck and thereby
relieve the retention of urine. The process of TURP
may have to be repeated several times as the prostate continues to enlarge and the frequency at
which surgery has to be repeated varies between
individuals. The procedure is usually performed
under general anaesthetic and is a relatively successful option for those who are fit enough to
undergo surgery.
Other forms of prostate ablation such as
transurethral incision of the prostate and laser
therapy are becoming increasingly popular,
although TURP is still the more usual procedure.
Other alternatives such as the use of radiowaves,
microwaves and prostatic stent insertion (a coillike catheter that is placed in the prostatic urethra)
are also used (Downey 2000). However, an open
6/22/2007 10:41:44 AM
98
PROMOTING CONTINENCE
Table 4.3 Drug dosage and potential side effects
Drug
Dosage
Side effect
5-alpha reductase inhibitor
Finasteride
5 mg od for 6 months, thereafter continue long term
Impotence 3% or reduced ejaculate
Selective alpha agents
Doxazosin
Indoramin
Prazosin
Terazosin
1–8 mg od
20 mg
0.5–2 mg bd
5–10 mg, gradually increasing od
Postural hypotension or dizziness
Super selective alpha agents
Alfuzosin
Tamsulosin
2.5 mg tds/5 mg bd
0.4 mg od
Urinary
drainage
bag
Continuous
bladder washout
with sterile saline
For inflation of balloon
with 30–50 ml sterile
water
Urethra
Symphysis
pubis
Symphysis
pubis
Prostatic bed
Prostate
Balloon
Cutting
electrode
Bladder
Shards
Bowel
(a)
Bowel
(b)
Figure 4.7 (a) Transurethral resection of prostate (TURP). (b) Three-way catheter allowing continuous irrigation of
the bladder to remove shards of prostate tissue.
Ch004-F10347.indd 98
6/22/2007 10:41:44 AM
Mainly men
Table 4.4 Side effects of prostate cancer
treatments
Treatment
Side effects
Radical
Incontinence
prostatectomy Impotence
Radiotherapy
Diarrhoea
Colitis
Rectal pain/bleeding
Urinary frequency
Impotence
Antiandrogen
Absent libido
Impotence
Hot flushes
Breast tenderness
Cardiovascular
problems
Chemotherapy
Most side effects
are temporary
and include
nausea, vomiting,
loss of appetite
Percentage with
side effects
65
80
10
5–10
40–60
90
100
prostatectomy will be done when men have very
enlarged glands as the length of time to remove
the tissue endoscopically would be excessive and
place the patient at risk of haemorrhage from the
resection site and deep venous thrombosis from
venous stasis after prolonged leg elevation in stirrups (Game & Farrer 1989).
Complications following TURP
All surgery carries risks. Prostate surgery can
result in urinary incontinence and/or retrograde
ejaculation, aside from the possibility of immediate postsurgical complications such as haemorrhage and hypovolaemic shock (Morrison et al
1994). Postsurgical urinary incontinence is attributed to the trauma associated with surgery in the
area of the bladder neck. Newer treatments such
as radiowave (transurethral needle ablation) and
laser therapy tend to be associated with less incontinence (Downey 2000).
Nearly all men who have undergone TURP
experience retrograde ejaculation. Small numbers
Ch004-F10347.indd 99
99
of men also suffer from erectile dysfunction for
reasons not well understood. Both erectile dysfunction and urinary incontinence are associated
with open prostatectomy (Downey 2000). It is
therefore particularly important that consent to
surgery is informed and that men are aware of the
potential urinary and sexual problems that may
follow. Sexual problems such as erectile dysfunction can sometimes be the result of anxiety rather
than a direct consequence of the surgery. Whatever the underlying cause of the problem, referral
to a specialist clinic is the main course of action.
The impact that a loss of potency and incontinence
can have on an individual in terms of self-image
should not be ignored and is considered in more
detail later.
A programme to assist the achievement of full
continence after prostatectomy should be instigated as soon as possible (see the ‘Advice sheet’
in Box 4.4). Several options exist to promote postsurgical urinary continence, including pelvic floor
re-education and bladder training programmes.
Evidence to support the effectiveness of PFMT
after TURP is weak and further research is required
to elucidate the benefit. A recent Cochrane Review
by Hunter et al (2006) of the conservative management of incontinence after TURP concluded that
its value remains unclear and that men’s symptoms tended to improve over time irrespective of
treatment. After radical prostatectomy, there may
be modest benefit up to 3 months post surgery of
initiating a PFMT routine. Nonetheless, some
support for the benefit of pelvic floor re-education
and bladder retraining in treating urinary incontinence does exist although more trials are clearly
indicated (DH 2000b). Insertion of an artificial urethral sphincter (Fig. 4.8) may be an option for a
small proportion of men with intractable postprostatectomy incontinence (Cheater 1996). Venn
et al (2000) reviewed long-term outcomes following sphincter implantation and concluded that
postprostatectomy incontinence seemed especially
amenable to such treatment. Fluid volume or specifically designed bladder training charts such as
that reproduced in Figure 2.9 can be useful in
helping both the patient and the healthcare professional assess and monitor the improvement of
urinary symptoms.
6/22/2007 10:41:44 AM
100
PROMOTING CONTINENCE
Box 4.4
sheet
General postprostatectomy advice
It is anticipated that following the removal of your
catheter you will experience a degree of urinary
urgency and leakage specifically on movement. To
reduce this leakage and help regain bladder control,
a programme of pelvic floor exercises and bladder
retraining is suggested.
1. Pelvic floor exercises help to retrain the muscles
around the bladder neck; try to do the exercises
five slow and five fast, 10 times a day (total 100
exercises).
2. After-dribble is also a common problem and can
be cured by a simple milking technique (squeeze
and lift) or push up behind the scrotum and
straighten the penis forward. This dislodges the
urine trapped in the bend of the urethra (the tube
from the bladder).
3. Bladder retraining will help rectify the frequency
and urgency. It is common to have altered bladder
sensation following prostate surgery. It is often
helpful to keep a diary of how often you pass
urine and then try to work on holding on or
delaying voiding for a few minutes. As your
bladder responds to this training the frequency
will reduce.
4. Fluid intake is important. Do not restrict your
fluids as concentrated urine will irritate your
bladder and make your urgency worse and also
increase your risk of urinary infection. Try to
consume 8–10 drinks a day and avoid caffeinated
fluids as these tend to irritate the bladder and
also have a diuretic effect (pass through the body
more quickly than water or decaffeinated drinks).
5. Constipation is also a common problem; ask your
healthcare professional for advice. A dietary
supplement of linseed may help.
6. It is generally advisable to purchase extra
protection for a few days. Disposable pads are
available in many shapes and sizes. Products are
available from most chemists but ask your
healthcare professional for advice.
Treatment of prostate cancer
The treatment and care of men diagnosed with
prostate cancer depends upon the extent of the
disease although the evidence base for these decisions is limited. For early stage cancer the options
Ch004-F10347.indd 100
Reservoir
of fluid
Periurethral
cuff
Cuff inflation
pump
Figure 4.8 An artificial sphincter.
include ‘watchful waiting’ (to determine whether
the cancer is active or slow growing), radical prostatectomy and radiotherapy. For cancer that has
spread beyond the prostate, radiotherapy and
hormone therapy remain the main treatment
options (DH 2000a). Treatment decisions are
largely dependent on the stage of the cancer at the
time of diagnosis. There are a number of options,
each with its advantages and disadvantages, and
include surgery, radiotherapy and drug therapy.
For early localised disease there are considered
two curative options:
1. Radical radiotherapy treats cancer by using highenergy rays that destroy cancer cells. For prostate cancer this may be achieved in two ways:
using an external beam that produces X-rays
that focus on the prostate from outside of the
body or using brachytherapy. The latter involves
the insertion (under a general anaesthetic) of
small radioactive seeds that release radiation
slowly over time. Both forms of radiotherapy
have side effects, but brachytherapy appears to
result in less damage to the bowel and less erectile dysfunction (DH 2000a).
2. Radical prostatectomy involves removal of the
prostate gland, prostatic capsule, seminal vesicles and prostatic urethra. Intraoperative nerve
stimulation techniques have been developed
6/22/2007 10:41:44 AM
Mainly men
which theoretically help reduce erectile dysfunction by assisting the surgeon to identify the
nerves. Laparoscopic approaches reduce hospital stays but it is unclear whether surgical or
oncological outcomes are improved. Cryoablation is rare except in select centres and is accompanied by significant incontinence and erectile
dysfunction.
For cancers that have spread beyond the prostate,
radiotherapy and hormone therapy are the options
of choice. Hormone therapy relies on the fact that
most prostate cancers depend on a continuing
supply of androgens, mainly testosterone. Reducing the amount of circulating testosterone by
removing the testicles (orchidectomy) or by
medical castration can help to control prostate
cancer and relieve symptoms for months or years.
Pharmacological treatment may often be used as
an adjunct to surgical intervention when margins
are positive and PSA starts to rise after radical
prostatectomy (DH 2000a).
There are two main types of pharmacological
therapy: luteinising hormone releasing hormone
(LHRH) analogues and total androgen ablation or
blockade. LHRH analogues act directly on the
pituitary gland to inhibit the release of follicle
stimulating hormone and luteinising hormone,
thus blocking production and release of testosterone. Total androgen blockade is used when a
patient no longer responds to other hormonal
treatments. Some antiandrogens are given in conjunction with an LHRH analogue or bilateral
orchidectomy. This regimen blocks the effect of all
circulating testosterone, including that produced
by the adrenal glands (Griefzu 2000). These treatments are not without side effects, in particular
hot flushes, decreased libido, erectile dysfunction,
lethargy, weight gain and mood changes. Moreover, bone loss and osteoporosis are serious consequences of hormone treatment that have, until
recently, been overlooked. Men on hormone
replacement are at high risk of hip fractures and
vertebral compression and must be advised to
follow a calcium-rich diet and include a daily
calcium supplement.
Cytotoxic chemotherapy using drugs such as
methotrexate to prevent growth of the malignant
cells may also be employed, but this is a late
Ch004-F10347.indd 101
101
stage treatment. However, none of the above nonsurgical treatments is shown to be superior and
none is wholly effective (Marsh 1992, DH 2000a).
At present there is no definitive evidence as to
which is the best treatment, especially for early
stage tumours, one reason being that some people
with early stage disease will often live 10 years or
more if no treatment is used. However, it is difficult to predict what course prostate cancer will
take in an individual. It is therefore essential that
the decision for treatment is shared with the patient
and information on outcomes is discussed. The
study by Hall et al (2003) shows that factors
beyond ‘cancer cure’ are important to patient treatment decisions (such as risk of incontinence and/
or sexual dysfunction) and improved educational
approaches are needed to aid decision making.
Radical surgery
Radical prostatectomy (RP) with a nerve-sparing
technique is seeing increased popularity in the UK
for localised disease. However, considerable morbidity exists following RP, including erectile dysfunction and urinary incontinence, the incidence
of which ranges from 2.5 to 87% depending on
definitions, method and time of data collection
(Krane 2000, Parekh et al 2003). Davidson et al
(1996) found that in 188 previously continent men
56% were incontinent following a radical prostatectomy, 21% were incontinent 3 months postoperatively and 14% were still incontinent at 1
year.
Moul et al (1998), using a patient self-reporting
incidence, found an 87.4% incidence of incontinence. In a similar study by McCallum et al (2001),
of the 180 men questioned, 21 were still incontinent 2 or more years after surgery. Half experienced stress urinary incontinence on urodynamics
as well as a component of detrusor dysfunction.
Impaired quality of life and reduced self-esteem
following radical prostatectomy have been
discussed by many authors (Butler et al 2001,
McCallum et al 2001, Alivizatios et al 2003).
Quality of life for men with incontinence is negatively affected, with many patients viewing incontinence as the most bothersome symptom.
However, Alivizatios et al (2003) suggest that,
depending on the individual’s opinion, inconti-
6/22/2007 10:41:44 AM
102
PROMOTING CONTINENCE
nence may be a minor problem which does not
have a large impact upon quality of life; their data
suggest that erectile dysfunction is the most disturbing complication after radical prostatectomy.
Postprostatectomy incontinence
It is thought that the pathophysiology of postprostatectomy incontinence may be due to sphincteric
dysfunction, detrusor dysfunction, or both. MacDiarmid (2001) describes stress urinary incontinence secondary to intrinsic sphincter deficiency
but many patients also have bladder dysfunction.
In a study by Chao and Mayo (1995), 57% reported
sphincter weakness and 39% detrusor dysfunction; 50% presented with a combination of factors.
Anastomotic strictures can occur in 5–24% of
patients (Chao & Mayo 1995).
It is thought that there are four main factors
affecting continence:
1. Pelvic muscle function
2. Trigonal denervation
3. Absence of urethral postvoid milking (Wille et
al 2000)
4. Bladder
instability
following
urethral
catheterisation.
Electromyography profile
Electromyography (EMG) is the study of bioelectric activity of muscles. The activity is measured
in microvolts and is a very useful adjunct when
teaching pelvic floor exercises because it enables
objective visual and audible measurement of
pelvic floor function (see also Ch. 3). EMG units
are widely available and are a very useful monitor
when assessing pelvic floor contraction. It has
been suggested that a low EMG profile is an identifiable risk factor (Rigby 2001); further research is
necessary to identify if preoperative low EMG
recordings also relate to a postoperative risk of
incontinence.
tatectomy and showed 70% improvement in
symptoms. Van Kampen et al (2000), in a similar
study, showed improved outcomes with intervention. However, the most recent Cochrane Review
(Hunter et al 2006) notes that studies vary widely
in quality, with small varied samples and imprecise outcome measures. Some evidence that PFMT
may help is a modest reduction in incontinence up
to 3 months post surgery; after that point, however,
the benefit is minimal. Sueppel et al (2001) suggested that starting biofeedback and PFMT before
surgery improved patient outcomes; their study
used biofeedback training.
There remain many unanswered questions
about the initiation of exercise both pre- and postoperatively. Of importance, however, is that men
value the support they receive from the nurse or
the physiotherapist, indicating the importance of
regular follow-up and supportive care after major
surgery for prostate cancer.
There are many variations on the PFMT protocols. Dorey (2001b) suggests that pelvic floor exercises should be individually taught to make sure
the patient is lifting up the pelvic floor and not
bearing down. Men can be encouraged to tighten
and lift the pelvic floor muscles as in the control
of flatus or the prevention of urine flow (Box 4.5).
It is important to carefully assess that the exercise
are done properly and some units recommend
digital rectal examination (Dorey 2001b).
Bladder retraining
Bladder retraining is useful to manage symptoms
of urinary urge and frequency (see Ch. 3). Bladder
retraining is used to describe the educational and
behavioural approach to re-establish bladder
control; the purpose is to restore a normal bladder
pattern. It is recognised that detrusor dysfunction
is a common complication of radical prostatectomy and many patients benefit from combined
bladder retraining and anticholinergic treatment.
Pelvic floor exercises
Fluid intake
A number of uncontrolled, non-randomised
studies have suggested benefits of pelvic floor
muscle exercise pre- and post radical prostatectomy. Burgio et al (1998) treated 20 men postpros-
Following prostate surgery men are advised to
drink enough to keep the urine clear in colour and
free from debris. Once the catheter is removed it
is important to review fluid intake both in terms
Ch004-F10347.indd 102
6/22/2007 10:41:44 AM
Mainly men
Box 4.5 Pelvic floor exercises for men
STANDING UP
Stand with your feet apart and tighten your pelvic
floor muscles as if you are trying to stop the flow of
urine. If you look in a mirror, you should be able to
see the base of your penis move nearer to your
abdomen and your testicles rise.
• Hold the contraction as strongly as you can
• Try to avoid pulling in your abdomen or tensing
your buttocks
• Perform three maximal contractions in the
morning, holding for the count of . . . seconds
• Perform three maximal contractions in the
evening, holding for the count of . . . seconds
SITTING DOWN
Sit on a chair with your knees apart and tighten your
pelvic floor muscles as if you were lifting your pelvic
floor off a drawing pin.
• Hold the contraction as strongly as you can
• Try to avoid pulling in your abdomen or tensing
your buttocks
• Perform three maximal contractions in the
morning, holding for the count of . . . seconds
• Perform three maximal contractions in the
evening, holding for the count of . . . seconds
LYING DOWN
Lie on your back with your knees bent. With the
knees apart, tighten your pelvic floor muscles.
• Hold the contraction as strongly as you can
• Try to avoid pulling in your abdomen or tensing
your buttocks
• Perform three maximal contractions in the
morning, holding for the count of . . . seconds
• Perform three maximal contractions in the
evening, holding for the count of . . . seconds
WHILE WALKING
Try lifting your pelvic floor up 50% when walking.
AFTER URINATING
After you have passed urine, try tightening your
pelvic floor muscles strongly to avoid the
embarrassing dribble.
THE KNACK
Try tightening just before and during activities which
increase your abdominal pressure such as coughing,
sneezing, lifting and getting out of a chair.
Reproduced with permission from Dorey (2001b).
Ch004-F10347.indd 103
103
of volume and type. There is much confusion over
how much we should drink and there is a consensus of opinion that a fluid matrix offers a validated
research-based approach (Abrams & Klevmark
1996). As a guide, a matrix suggests intake based
on body weight; for example, a 76 kg (12 st) person
should aim to consume eight drinks (2.3 litres or
4.2 pints) per day (30 ml/kg).
Bowel care
There are very few data on bowel management
postprostatectomy; however, Hall et al (2003), in
a study on decision making, found bowel dysfunction to be a common unpleasant surprise after
treatment. It is recommended that pre- and postoperative advice be given on avoiding constipation, for which a dietary supplement of linseed can
be very beneficial.
Containment advice
Moul et al (1998) reported that 39% of patients
needed protection to contain incontinence. Products for men are rarely available in chemists and
more frequently they purchase either inappropriate general containment products available in
many large retail outlets or resort to female products and even babies’ nappies. An overview of
containment products and appliances for men is
provided below, with more detailed discussion in
Chapter 10.
MANAGING INCONTINENCE
Although many people with incontinence can be
successfully cured with appropriate management,
many others have persistent incontinence that can
only be managed symptomatically with appliances such as pads to ensure social continence (see
Ch. 10). Alleviating the often unpleasant and
undesirable consequences of urinary incontinence
may be a short-term measure (during treatment)
or a long-term strategy when other options have
been exhausted. Management options for males
can be grouped into two major categories: containment aids and conduction aids. Examples include
small pouches for dribbling incontinence and
urinary sheath drainage systems, respectively.
6/22/2007 10:41:44 AM
104
PROMOTING CONTINENCE
There are some absorbent products for low
levels of incontinence specifically designed for
males: the ‘dribble pouch’ is designed to fit over
the penis and absorb small amounts of incontinent
urine; the ‘leaf’ fits over both penis and scrotum.
These pouches are usually disposable and are held
in position by means of a washable jockstrap or
tight-fitting underpants.
Conduction aids
Urinary sheaths
The urinary sheath is a method of managing
urinary incontinence, which is unique to males,
sometimes referred to as condom or external
catheters. Sheaths are supplied as one- or twopiece systems, and some of those available come
complete with their own applicator. A number of
problems have been associated with the use of
urinary sheaths such as the sheath becoming
detached, irritation of penile skin and difficulty in
self-application if manual dexterity is poor. Proper
patient assessment, correct fitting and follow-up
should ensure best use of the product although
not all men can be successful with a sheath system.
It is doubtful whether there is one universal best
sheath system and it may be advisable to provide
the patient with a selection to try.
A number of criteria must be satisfied in order
for an individual to be fitted with a urinary sheath,
whether it is a two-piece or a one-piece system.
The nurse or person fitting the sheath should
check that:
●
●
●
●
the penis is not retracted
the skin is not broken or inflamed (although a
barrier cream may be used)
the individual is not confused and at risk of
pulling the sheath off or leaving it on
indefinitely
the individual has sufficient manual dexterity if
self-caring, or alternatively that the sheath can be
applied by a carer or health professional.
Despite the fact that these devices come in a variety
of designs and that most manufacturers provide a
range of sizes, it is essential that the penis is not
too retracted for the successful attachment of a
sheath. If the penis is retracted in any way, if the
Ch004-F10347.indd 104
man is obese or if there is herniation around the
base of the penis, then it is unlikely that this technique can be applied. It is helpful to try a sheath
over a 5-day period to test if this approach is suitable for the individual. If the sheath can be kept
in place for more than 12 h then it is probably an
appropriate technique. Confused men are very
likely to pull off a urinary sheath and this method
of management may be unsuitable for such clients
(Irvine 1991). This may account for the very low
use of urinary sheaths in psychogeriatric units
(Stott et al 1990). Sheaths are generally not suitable
for men with obstruction, or with symptomatic
urinary infection (Button et al 1998). Guidance on
fitting a penile sheath is provided in Box 4.6. See
also the case study in Box 4.7.
Drainage systems for use with a sheath are
similar to those used with an indwelling catheter
(see Ch. 10). These include free-standing and
smaller body-worn drainage bags. Urine bags are
made by several manufacturers and come in a
variety of sizes and shapes, with different methods
of attachment and a variety of tap fittings. As with
other products, patient assessment (including leg
length and manual dexterity) and individual
patient preference are vital considerations when
selecting a product.
Pubic pressure device
A second group of male conduction aids are those
generally termed body-worn urinals or pubic
pressure devices (see Ch. 10). This form of
appliance is most often used in men who are
unable to wear either a dribble pouch or a urinary
sheath because they have a retracted penis – the
penis is effectively too small to hold the appliances
in place. Pubic pressure devices work by exerting
pressure around the base of the penis and are
fitted by an experienced appliance fitter. The
device consists of a rubber cone held in place
by means of waist and groin straps and attached
to a leg drainage bag. Users sometimes complain
of discomfort such as sweating and soreness,
which is perhaps not surprising given the
bulkiness of the device. In suggesting this
option, consideration needs to be given to the individual’s ability to apply the product and its
acceptability.
6/22/2007 10:41:44 AM
Mainly men
Box 4.6 Fitting a penile sheath
When a decision has been made to try a penile
sheath for managing urinary incontinence, part of the
success for the wearer is selecting the right size, type
and fitting of the sheath. Most manufacturers offer a
one- or two-piece system in a range of sizes from
22 mm to 35 mm.
1. First, the size of the penis can be measured
using a specially designed measuring device
provided by the manufacturer. The
circumference is estimated by placing the
device at the base of the penis so that the fit is
not too tight or too big. The size of the sheath
required is shown on the measuring device at
that position.
2. Once the size is chosen, some samples of
different makes of sheath should be given for
the patient to choose from.
3. Wash and dry the penis but do not apply talc or
creams as this may prevent the sheath from
forming a secure seal against the skin.
4. Take the sheath from the packet and using the
packet, cut a hole in the middle which can go
over the penis to keep the pubic hair away from
the shaft of the penis. Make sure the foreskin is
kept forward.
5. If using the one-piece self-adhesive sheath,
place the penis into the sheath leaving a small
gap (about 1 cm) at the bulbous end and then
gently unroll the sheath the length of the penis
and secure firmly by pressing on the penis.
6. If using the two-piece system, carefully stretch
the adhesive strip before winding it around the
shaft of the penis. This allows for any change in
penis size while wearing the sheath. Roll the
sheath over the adhesive strip in the same way
as described above.
7. Remove the protective ‘collar’ made from the
packet and discard. Attach the drainage bag
securely making sure that the tube’s connector
goes past the ‘waist’ of the outlet tube and
then strap to the leg (straps are provided with
bags).
8. Sheaths are durable for 24 h’s wear, but
sometimes they remain in place for a longer
period.
9. To remove a sheath, simply roll it off over the
tip of the penis and discard.
10. Wash and dry the genital area thoroughly after
removing the sheath and before replacing it
with a fresh one.
Ch004-F10347.indd 105
105
Indwelling catheterisation
Catheterisation is usually considered a last resort
in the management of incontinence, and indwelling catheters are usually only chosen when other
strategies have failed. Chapter 10 discusses the
issues associated with catheterisation and catheter
management. However, catheterisation is the
usual choice in cases of AUR to decompress the
bladder to prevent ureteric reflux and backpressure to the kidneys.
Acute urinary retention (AUR)
AUR refers to the sudden inability to pass urine
and is characterised by painful distension of the
bladder. It is a common condition; more than 1 in
10 men in their 70s will experience AUR, while the
risk for men in their 80s is nearly 1 in 3 (Jacobsen
et al 1997). However, there is some evidence that
the incidence is declining, an observation that may
partly be explained by a trend towards earlier
presentation of men with LUTS (Clifford et al
2000). Our understanding of why men develop
AUR is limited, but there are several elements that
contribute to its development:
●
●
●
●
Events that increase the resistance to the flow of
urine (e.g. prostatic obstruction, urethral stricture or increase in muscle tone)
Interruption of the sensory innervation of the
bladder wall (e.g. diabetic cystopathy) or the
motor supply to the detrusor muscle or secondary to the influence of drugs
Events that lead to overdistension of the bladder
(e.g. after general anaesthesia, particularly for
orthopaedic procedures)
Prostatic infarction or other causes of
inflammation.
The primary management of AUR is catheterisation, which may be undertaken by general practitioners or hospital doctors. A urethral catheter is
most commonly used in the UK (Manikandan et
al 2004) although some favour a suprapubic
approach, particularly if the catheter is going to
stay in place for some time.
As a catheter in place at the time of surgery is
associated with an increased risk of bleeding and
sepsis due to bacterial colonisation, it is preferable
6/22/2007 10:41:45 AM
106
PROMOTING CONTINENCE
Box 4.7
Case study: Examining the effectiveness of continence care
Henry is a 76-year-old gentleman of previous good
health who was admitted to an acute medical ward
following a cerebrovascular accident (CVA). He had
recovered well from his stroke and was hoping to
return home in the near future. However, he was still
experiencing problems with his bladder. Although
continent during the day, Henry wet the bed most
nights. The nurses on the ward had fitted him with a
urinary sheath after his attempts to use urine bottles
had proved unsuccessful. Henry was unable to fit the
sheath himself and even when fitted by the nurses it
rarely stayed on all night.
Henry had lived alone prior to admission but planned
to live at his daughter’s on discharge from hospital.
However, there were two practical difficulties: ‘Who
would apply the sheath?’ and ‘How would they deal with
the washing and the spoiling of bed linen/mattress when
the sheath fell off?’ The continence nurse specialist was
asked to help.
Henry explained his distress, frustration and
embarrassment. The care plan in the nursing notes
referred to the need to test the patient’s urine, assess
his constipation risk and do a 3-day continence chart.
The evaluation column of the care plan recorded that a
urinary sheath had been applied and made reference to
a ‘wet bed’. The notes indicated that the urine test was
‘NAD’ and that ‘bowels’ had been ‘well opened’ on
several occasions. A 3-day fluid volume chart had been
partially completed 2 weeks previously and filed in the
notes. There was no evidence that the doctor had been
informed of the patient’s continence problem.
QUESTIONS
• What factors may have influenced the effectiveness
of Henry’s care?
• What could be done to ensure that his continence
care was more effective?
POINTS FOR REFLECTION
It may help to consider the following issues:
• Why was urine bottle use unsuccessful? Had his
stroke or another coexisting complaint affected
Henry’s grip?
• Why wasn’t the sheath staying on? There was no
reference to the size of the appliance in the care
plan. Had the correct sheath size been determined
Ch004-F10347.indd 106
and communicated to everyone who was involved in
assisting Henry to change the appliance?
• Was a sheath appropriate? Henry could not fit it
himself and no one was available to help at home.
He did not like the sheath. Had he been offered a
choice?
• Was Henry’s incontinence really intractable? What
was really causing it? The fluid volume chart was
incomplete. Medical staff were not aware of the
continence problem. Would Henry’s incontinence
problem have benefited from the knowledge of other
members of the multidisciplinary team?
WHAT WOULD HAVE CONSTITUTED A DESIRABLE
OUTCOME FOR HENRY?
• Option One: Continence.
• Option Two: A management solution, acceptable to
Henry and manageable by him with minimal risk of a
wet bed with resultant distress.
TREATMENT PLAN
Henry’s continence problem was thoroughly assessed
and an individual plan of care established. The
assessment revealed a high urine output at night, which
was also the time Henry was least capable of reaching
the toilet/using a bottle because he was tired and had
taken sleeping pills whilst in hospital. (He had been
unable to sleep through worry.)
Henry was prescribed furosemide (frusemide) at 6
p.m. each evening to eliminate his urine load and reduce
the high volume of urine produced at night when he
was least able to cope with it. He was provided with a
urine bottle with a non-spill adapter, as his grip was
weak, especially when tired. He was also weaned off his
sleeping pills as these had been started during his
hospital stay and had added to his drowsiness when he
did need to awaken to pass urine.
OUTCOMES
Henry was continent on discharge (but bought a
protective bed sheet and took the continence nurse’s
contact number just in case!). Effective care had been
achieved based upon a comprehensive assessment of the
problem, goals that were patient focused and negotiated
with Henry and his daughter, and an individualised plan
of care which served to ensure that all those involved
knew of his requirements.
6/22/2007 10:41:45 AM
Mainly men
107
Box 4.8 Case study: Intermittent self-catheterisation
Mr Williams is a 73-year-old retired gentleman living in
his own semi-detached bungalow within walking
distance of the shops and his local pub. He worked as a
lorry driver for 30 years and considers himself to be
pretty healthy. He has been a non-smoker for over 40
years. He was referred by his wife who was nagging him
about having to wash underwear smelling of urine.
When seen in the continence clinic, Mr Williams
complained of: leaking urine with walking, coughing or
getting up quickly. He related the problem to the ‘pills’
the doctor gave him for his prostate. He had gone to see
his GP about 3–4 months ago because of increasing
difficulty in starting his stream; once started it would
stop and start and often dribble at the end. It also took
him several minutes to empty his bladder. He had no
symptoms of urgency and was only waking up at night
once or twice, although he was not sure if he awoke
because of a full bladder because he didn’t usually feel
full even if he went to the toilet. He thought he woke
up because recently his penis and anal area had been
getting itchy. He was putting cream on a few times a
day and at night to help soothe the irritation. His GP
had checked his prostate and thought the pills might
help. They had improved the volume of the urine stream
but made him a bit dizzy when he stood up quickly and
seemed to make the ‘dribbling’ worse.
Mr Williams has type 2 diabetes controlled by diet
and hypoglycaemics (Diabinese and Metformin). He
rarely goes to his GP and does not remember the results
of his most recent blood sugar test or when it was
taken. He denies any history of heart disease or
hypertension but erectile function is poor. There is no
complaint of haematuria, dysuria or UTI; bowels are
regular with no straining or flatus or stool incontinence.
On examination, his ankles are oedematous extending up
to mid-calf and there are signs of venous stasis in both
ankles and calves. Abdominal examination reveals an
obese abdomen, bladder seems palpable but it is difficult
to be certain because of abdominal fat. There is a
bilateral, moist, red patchy rash in inguinal creases.
Post-void residual ultrasound was 1500 ml after a
prolonged void of 300 ml. BP after lying down for 5 min
was 163/100. Urinalysis (by dipstick) is positive for
protein; glucose; leukocytes.
Ch004-F10347.indd 107
TREATMENT PLAN
The most probable diagnoses are: incomplete emptying,
likely due to diabetic neuropathy; bacteriuria due to
chronic urinary retention; hypertension; risk of skin
breakdown and infection. Ask Mr Williams what he
thinks has contributed to his bladder problems and what
his goals for treatment are. Once these are established,
explain to Mr Williams that his bladder may not be
emptying properly because his diabetes has affected the
nerve supply to the bladder muscle so that it doesn’t
contact well or give him the sensation of having a full
bladder. The neuropathy may also be the cause of his
poor erections. Explain that poor erections may be a
sign of cardiovascular disease and that a visit to his
family physician for a check up is warranted. Suggest
that he learns how to self-catheterise to drain his
bladder effectively and show him how to do this. Ask
him to keep a record of how much he drinks and the
type of fluid, how much he voids spontaneously and
how much he catheterises. Request that initially
catheterising should be done 4 times a day (ideally to
keep the bladder volume at approximately 500 ml or
less); recommend topic antifungal cream for the skin
rash on the perianal area and glans penis. Obtain urine
for culture and sensitivity and microscopy. Mr Williams
should be advised to go to his GP for a full check up,
including blood pressure, eyesight changes, blood
glucose levels, urinalysis report and review of his
medication. He may also benefit from seeing the
nurse in the outpatient diabetic clinic for advice on
foot and skin care. Request that Mr Williams return to
see you in 2 weeks for a follow-up visit, at which
time you will review his fluid volume diary and see
how he is managing with the catheterisations; you will
also check on the status of his skin rash which you
explain is common in people with incontinence but is
treatable first by the antifungal cream and then by
keeping the area dry and protected with a cream.
(NB: Mr Williams should not take sulphonamide
antibiotics when he is taking Diabinese for his diabetes).
Reinforce the importance of having both his blood
pressure and blood sugars under good control in order to
preserve his eyesight, renal health and cardiovascular
status.
6/22/2007 10:41:45 AM
108
PROMOTING CONTINENCE
that men undergo a trial without catheter (TWOC)
after an episode of AUR in the hope that perioperative morbidity will be reduced even if they do
not avoid surgery altogether.
A further reason for trying to avoid emergency
surgery for this condition is that men who had
a prostatectomy following AUR had a worse
outcome in terms of symptom reduction and
improvements in quality of life than those undergoing planned prostatectomies as demonstrated
in the National Prostatectomy Audit (Mebust et al
1989). There is some evidence to suggest that
catheter drainage combined with alpha-blockers
may be associated with a good chance of successful voiding (McNeill et al 1999, 2004).
Choice of product
Continence appliances are not without their problems and the decision to use/choice of product
should be carefully considered (see Ch. 10).
Although forming part of a set of consensus guidelines aimed at the primary healthcare team, the
following algorithm and five principles are equally
helpful in guiding decision making on product
use (Button et al 1998):
●
●
●
Intermittent self-catheterisation
●
Intermittent self-catheterisation (ISC) is now the
option of choice for a wide range of urinary problems involving poor bladder emptying, offering
a viable and more convenient alternative to longterm urethral catheterisation (see Ch. 10). ISC is
currently regarded as suitable for most patients
with bladder symptoms related to incomplete
emptying/urinary retention (DH 2000b). The main
advantage of ISC is that, after a brief period
of training, it can be carried out by the patient
in his own home without the need for regular
nursing supervision. ISC is suitable for almost any
patient, providing they have the necessary
cognitive ability, manual dexterity and motivation
(see Box 4.8).
Occlusive devices
Apart from artificial sphincters, which are inserted
surgically and mentioned above, the only other
form of device aimed at preventing outflow of
urine is the penile clamp. Penile clamps are an
option for a carefully selected group of men who
have normal penile sensation, cognitive ability
and manual dexterity. They are not recommended
for men with neuropathic disorders such as diabetes or multiple sclerosis. Intermittent use (e.g.
when swimming) can greatly enhance men’s confidence in public places. Good patient teaching
about the misuse of the penile clamp is mandatory
to prevent skin breakdown, pain or oedema.
Ch004-F10347.indd 108
●
The restoration of continence should be the aim
for all persons.
Assessment should precede any issue of aids or
appliances.
Individual patient/client choice should be a key
consideration in determining a suitable management strategy.
Care should include education in the correct use
of any aid or appliance issued.
Product suitability and requirements should be
reviewed regularly.
When choosing a product, the National Prescribing Centre (1999) suggests the use of the EASE
mnemonic:
●
●
●
●
How Effective is the product? (At containing
odour and urine?)
How Appropriate is the product for this patient?
(Can they manage it easily, is it comfortable and
discreet?)
How Safe is the product? (Is it environmentally
friendly, easy to dispose of?)
Is the prescription cost Effective?
In addition to comprehensive patient assessment
and careful choice of product (which includes
incorporation of patient views), it is essential that
products are used effectively and according to the
manufacturer’s instructions.
Sexuality and LUTS
The potential impact of urinary incontinence in
general and the use of appliances in particular on
the individual should not be underestimated.
Alterations in body image, relations and sexual
activity are issues that it would be all too easy to
overlook (Royal College of Nursing 2000).
Although these are arguably not subjects to be
6/22/2007 10:41:45 AM
Mainly men
broached until a sufficiently trusting relationship
has been established between the healthcare practitioner and the patient/client, they are important
considerations.
The penis is considered by many to be the focus
of male sexuality and Lawler (1991) has suggested
that compared with female sexuality, male sexuality is more genital, less diffuse and more concerned with power and performance, and is more
physical. Physiological changes in an older man
such as prostatic disease will affect his genitalia
and sexual performance. The argument for healthcare professionals to introduce questions about
sexual function into their assessments of men presenting with LUTS is simple. There is now clear
evidence that men with urinary symptoms are not
only at an increased risk of sexual dysfunction but
also that problems with sex significantly reduce
the quality of these men’s lives. Moreover, knowledge about a man’s sexual function can significantly influence the management of his LUTS
(Coombe 2003).
The point behind asking questions about a
patient’s sex life is that the information it reveals
can have a significant influence on the choice of
management. It is well known that several management options for BPH alone have sexual consequences. Surgery causes ejaculatory dysfunction
in around two-thirds of patients, although it may
improve erectile dysfunction (Brookes et al
2002). Finasteride can lead to decreased libido,
erectile dysfunction and ejaculatory disturbance
(Debruyne et al 1998) and the alpha-1A selective
blocker tamsulosin may cause a dose-dependent
incidence of abnormal ejaculation (Schulman et al
2001). In contrast, the alpha-1 selective blocker
alfuzosin has been shown to have no significant
link to sexual dysfunction (van Kerrebroeck et al
2000). Choosing the right medication is therefore
essential.
With regard to appliances and pads, essentially
the message regarding sexuality is that a great
deal can be done to maintain sexual image and
also to maintain sexual activity. When a man is
wearing a urinary sheath or a urinary catheter,
provided that the collecting bag has been fitted
correctly to the inside of the leg, there is no need
for anyone else to know that a device is being
worn. On the other hand, the use of pads may be
Ch004-F10347.indd 109
109
more obvious as many of these are bulky. With
improved products, which are smaller and more
absorbent, the situation is improving. As with any
kind of appliance, good skin hygiene is essential
in order to prevent odour and discomfort. These
measures will reduce the impact of urinary incontinence on sexuality.
One of the problems arising from the use of
devices to manage urinary incontinence is that of
altered body image and this is particularly the
case where an appliance is being worn (Wheeler
1991). Sexual activity is possible even with an indwelling urinary catheter in situ. The catheter can
be taped back along the shaft of the penis, or alternatively it can be removed altogether and replaced
after intercourse. Replacement is usually done by
the man himself or a partner/carer who has been
taught the technique. The outlet to the bladder is
blocked during erection of the penis so it is unlikely
that urine will leak during intercourse.
Involving a partner in the care of an individual,
whether directly in terms of changing catheter bags
or continence pads, or indirectly as a source of
support, must not be done without careful consideration. Blannin (1987) suggests that where a
partner adopts the role of ‘nurse’ this may produce
conflicts in the relationship resulting in a loss of
self-esteem and sexual desire. It may also be
prudent to emphasise that age is no barrier to experiencing a close sexual relationship (Duffin 1992).
Clearly, consideration of sexuality and sexual
function requires a sensitive approach and discussion between partners. It is possible that specialist
advice may need to be sought. Any sexual dysfunction as a result of urinary incontinence should
be brought to the attention of an appropriate
therapist, such as a specially trained counsellor,
a continence advisor or general practitioner
who may be able to offer help and advice. It may
also be appropriate to inform individuals and
their carers of the existence of local support groups
and services, as well as national organisations
such as the Continence Foundation (http://www.
continence-foundation.org.uk).
CONCLUSIONS
In the nursing strategy document Making a Difference (DH 1999) continence is identified as one of
6/22/2007 10:41:45 AM
110
PROMOTING CONTINENCE
the eight fundamental and essential aspects of care
that sometimes fall ‘below acceptable standards’.
LUTS in men is common and is usually associated
with the prostate but it is essential that a thorough
assessment of all possible causes is investigated
before making a diagnosis. For men, incontinence
impacts on every aspect of their life including
their sexuality. For any man the diagnosis of prostate cancer is devastating; the treatment can also
leave many men with significant incontinence.
Through sharing of information and awareness of
potential problems, nursing care can improve. As
healthcare professionals we are challenged to
provide care for a growing cohort of patients with
post radical prostatectomy incontinence. There
is no doubt that these men need advice and
support.
KEY POINTS FOR PRACTICE
●
●
Overactive bladder symptoms are just as common
in men as in women, but incontinence is more
prevalent in women
The prostate plays a major role in bladder function in men over the age of 50 years
●
●
●
Radical surgery for prostate cancer can cause
stress incontinence in men. The treatment is the
same as for women, i.e. pelvic floor exercises
Alpha-blockers are recommended as first-line
treatment in benign prostatic hyperplasia (BHP);
they have a rapid onset of action
5-Alpha reductase inhibitors reduce the volume
of the prostate and reduce obstruction in BPH
Useful website
http://www.orchid-cancer.org.uk: Orchid Cancer
Appeal provides a wealth of information on
testicular and prostate cancer ranging from
innovative research to patient awareness campaigns. Message boards allow both patients and
medics alike to interact on this award-winning
site.
ACKNOWLEDGEMENTS
With acknowledgements to Katherine Moore for
her contribution to this chapter.
References
Abrams P 1997 Urodynamics, 2nd edn. Springer, London
Abrams P, Klevmark B 1996 Frequency volume charts: an
indispensable part of lower urinary tract assessment.
Scandinavian Journal of Urology and Nephrology Supplement 179:47–53
Alivizatios G, Skolarikos A, Laguna P 2003 Recent data upon
impotence, incontinence and quality of life issues concerning radical prostatectomy. Archivos Españoles de Urología
56(3):321–330
Ball A, Feneley R, Abrams P 1981The natural history of
untreated prostatism. British Journal of Urology
533:613–616
Barry M J, Fowler F J, O’Leary M P et al 1992 The American
Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology 148:1549–1557
Billington A 1999 Prostate disease. Nursing Standard
13(25):49–54
Blandy J 1998 Lecture notes on urology. Blackwell Science,
Oxford
Blannin J 1987 Incontinence: men’s problems. Community
Outlook Feb:27–28
Boyle P, Robertson C, Mazzetta C et al 2003 The prevalence
of male urinary incontinence in four centres: the UREPIK
study. British Journal of Urology 92:243
Ch004-F10347.indd 110
Brookes S T, Donovan J L, Peters T J et al 2002 Sexual dysfunction in men after treatment for urinary tract symptoms:
evidence from randomised controlled trial. British Medical
Journal 324:1059–1061
Button P, Roe B, Webb C et al 1998 Consensus guidelines:
continence promotion and management by the primary
healthcare team. Whurr, London
Burgio K L, Stutzman R E, Engel B T 1998 Behaviour training
for post prostatectomy urinary incontinence. Journal of
Urology 141(2):303–306
Butler L, Downe-Wamboldt B, Marsh S et al 2001 Behind the
scenes: partners’ perception of quality of life post radical
prostatectomy. Urologic Nursing 20(4):254–258
Catalona W, Partin A, Slawin K et al 1998 Use of the percentage of free prostate specific antigen to enhance differentiation of prostate cancer from benign prostatic disease: a
prospective multicenter clinical trial. Journal of the American Medical Association 279:1542–1547
Cancer Research UK 2006 Incidence and mortality rates for
prostate cancer. Online. Available: http://info.cancerresearchuk.org/cancerstats/types/prostate/incidence
Chamberlain J, Meilia J, Moss S, Brown J 1997 The diagnosis,
management, treatment and costs of prostate cancer in
England and Wales. Health Technology Assessment 1:3
6/22/2007 10:41:45 AM
Mainly men
Chao R, Mayo M E 1995 Incontinence after a radical prostatectomy. Journal of Urology 154(1):16–18
Cheater F 1996 Promoting urinary continence. Nursing
Standard 10(42):47–54
Clifford G M, Logie J, Farmer R D 2000 How do symptoms
indicative of BPH progress in real life practice? The UK
experience. European Urology 38(1):48–53
Coombe M 2003 Sex and the LUTS consultation. Men’s Health
2(2):50–51
Continence Foundation 2000 Making a case for investment in
integrated continence services: a source book for continence services. Continence Foundation, London
Davidson P, van den Ouden D, Schroeder F H 1996 Radical
prostatectomy: prospective assessment of mortality and
morbidity. European Urology 29:168–173
Debruyne F M, Jardin A, Colol D et al 1998 Sustained release
alfuzosin, finasteride and combination of both in the treatment of benign prostatic hyperplasia. European Urology
34:169–175
Denning J 1996 Male urinary incontinence. In: Norton C
(ed) Nursing for continence. Beaconsfield, London,
p 153–169
Department of Health 1999 Making a difference: strengthening the nursing, midwifery and health visiting contribution to health care. DH, London
Department of Health 2000a The NHS prostate cancer programme. DH, London
Department of Health 2000b Good practice in continence
services. DH, London
Desmond P V, Thompson I, Zeidman E, Mueller E 1993 Morbidity with contemporary prostate biopsy. Journal of
Urology 150:1425–1426
Dorey G 2001a Male patients with lower urinary tract symptoms 2: treatment. In: Pope Cruikshank K, Woodward S
(eds) Management of continence and urinary catheter
care. BJN Monograph. Mark Allen, London
Dorey G 2001b Conservative treatment of male urinary
incontinence and erectile dysfunction. Whurr, London
Downey P (ed) 2000 The prostate. In: Introduction to urological nursing. Whurr, London
Duffin H 1992 Assessment of urinary incontinence. In: Roe B
H (ed) Clinical nursing practice: promotion and management of continence. Prentice Hall, New York, Chapter 3
Feneley R C L, Gingell J C, Abrams P et al 1999 Urology
guidelines for GPs. Urological Institute, Bristol
Game C, Farrer H 1989 Disorders of the male reproductive
tract. In: Game C, Anderson R E, Kidd J R (eds) Medical–
surgical nursing: core text. Churchill Livingstone, Melbourne, p 644–653
Garroway W, Collins G R 1991 High prevalence of benign
prostatic hypertrophy in the community. Lancet
338:469–471
Griefzu SP 2000 Prostate cancer. Registered Nurse
63(6):26–32
Hall J D, Boyd J C, Lippert M C et al 2003 Why patients
choose prostatectomy or brachytherapy for localised prostate cancer: results of a descriptive study. Urology 61(2):402
–407
Ch004-F10347.indd 111
111
Hunskaar S, Sandvik H 1993 One hundred and fifty men with
urinary incontinence. Scandinavian Journal of Primary
Health Care 11:193–196
Hunskaar S, Burgio K, Clark A et al 2005 Epidemiology of
urinary and faecal incontinence and pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury S, Wein A (eds)
Incontinence. Health Publication, Paris
Hunter K F, Moore K N, Cody J, Glazener C M J 2006 Conservative management of post prostatectomy incontinence
(Cochrane Review). Cochrane Library Issue 3. Update
Software. John Wiley, Chichester
Irvine L M 1991 Continence in later life. In: Garrett G (ed)
Healthy ageing: some nursing perspectives. Wolfe,
London, p 124–130
Jacobsen S J, Jacobsen D J, Girman C J et al 1997 Natural
history of prostatism: risk factors for acute urinary retention. Journal of Urology 158:481–487
Kellogg Parsons J, Partin A 2004 Applying complexed prostate specific antigen to clinical practice. Urology
63:815–818
Kirby M 1997 Making a diagnosis. Benign prostatic hyperplasia. Pulse 4–5
Kirby R 1997 Management of common prostatitis syndromes.
Trends in Urology, Gynaecology and Sexual Health
Nov/Dec:37–43
Kirby R, McConnell J 2004 Benign prostatic hyperplasia: fast
facts, 4th edn. Health Press, Albuquerque, NM, Chapter
2
Kirby R, Fitzpatrick J, Kirby M, Fitzpatrick A 1994 Shared
care for prostatic diseases. Isis Medical Media, Oxford,
Chapter 2
Krane R J 2000 Urinary incontinence after treatment for
localised prostate cancer. Molecular Urology 4(3):279–
286
Lawler J 1991 Behind the screens. Churchill Livingstone,
Melbourne
McCallum T, Moore K, Griffiths D 2001 Urinary incontinence
after radical prostatectomy: implications and urodynamics. Urological Nursing 21(2):113–119
MacDiarmid S A 2001 Incontinence after radical prostatectomy: pathophysiology and management. Current
Urology Reports 2(3):209–213
McNeill S A, Daruwala P D, Mitchell I D C et al 1999 Sustained release alfuzosin and trial without catheter after
acute urinary retention: a prospective, placebo-controlled
trial. BJU International 84:622–627
McNeill S A, Rizvi S, Byrne D J 2004 Prostate size influences
outcome following presentation with acute urinary retention. BJU International 94(9):1407–1419
Marsh M 1992 Malignant disease of the prostate gland.
Nursing Standard 6(36):28–31
Malmstein U 1997 Urinary incontinence and lower urinary
tract symptoms: an epidemiological study of men aged
45–99. Journal of Urology 158:1733–1737
Manikandan R, Srirangam S J, O’Reilly P H, Collins G N 2004
Management of acute urinary retention secondary to
benign prostatic hyperplasia in the UK: a national survey.
BJU International 93(1):84–88
6/22/2007 10:41:45 AM
112
PROMOTING CONTINENCE
Mebust W K, Holtgrewe H L, Cockett A T K, Peters C and
Writing Committee 1989 Transurethral prostatectomy:
immediate and postoperative complications. A comparative study of thirteen participating institutions evaluating
3885 patients. Journal of Urology 141:243–247
Milliard R J 1989 After dribble. In: Bladder control – a simple
self-help guide. William & Wilkins, Broadway, NSW,
Australia
Morrison M, Shandran T, Smithers F, Fawsett J N 1994 The
urinary system. In: Alexander M, Fawsett J N, Runciman
P J (eds) Nursing practice: hospital and home. Churchill
Livingstone, Edinburgh, p 291–324
Moul J W, Mooneyham R M, Kan T C et al 1998 Preoperative
and operative factors to predict incontinence, impotence
and stricture after radical prostatectomy. Prostate Cancer
and Prostatic Diseases 1(5):242–249
National Prescribing Centre 1999 Prescribing Nurse Resource
Pack: urinary incontinence. National Prescribing Centre,
Liverpool
National Institute for Clinical Excellence (NICE) 2000 Urinary
tract (outflow) symptoms. A guide to appropriate referral
from general to specialist services. NICE, London
National Screening Committee 2000a Second report of UK
National Screening Committee. DH, Wetherby
National Screening Committee 2000b Information sheet on
screening for prostate cancer. DH, Wetherby
Parekh A R, Feng M I, Kirages D, Bremner H, Kaswick J,
Aboseif S 2003 The role of pelvic floor exercises on post
prostatectomy incontinence. Journal of Urology
170(1):130–133
Rigby D 2001 Urinary incontinence following a radical prostatectomy: is there a need for intervention? British Journal
of Nursing 10(supplement 21):8–9
Royal College of Nursing 2000 Sexuality and sexual health in
nursing practice: a discussion document. RCN, London
Royal College of Physicians 1995 A report of the Royal
College of Physicians. Incontinence: causes, management
and provision of services. RCP, London
Selley S, Donovan J, Faulkner A et al 1997 Diagnosis, management and screening of early localised prostate cancer.
Health Technology Assessment 1:2
Schulman C C, Lock T M, Buzelin J M et al 2001 Long term
use of tamsulosin to treat lower urinary tract symptoms/
Ch004-F10347.indd 112
benign prostatic hyperplasia. Journal of Urology
166:1358–1363
Stenzelius K, Mattiason A, Hallberg IR, Westergren A 2004
Symptoms of urinary and faecal incontinence among
men and women 75+ in relation to health complaints
and quality of life. Neurourology and Urodynamics
23(3):211–222
Stott D J, Dutton M, Williams B O et al 1990 Functional capacity and mental status of elderly people in long term care
in Glasgow. Health Bulletin 48:17–24
Sueppel C, Kreder K, See W 2001 Improved continence outcomes with preoperative pelvic floor muscle strengthening exercises. Urologic Nursing 21(3):201–210
Thom D 1998 Variations in estimates of urinary incontinence
prevalence in the community: effects of differences in definition, population characteristics, and study type. American Geriatric Society 46:473
Van Kampen M, De Weerdt W, Van Poppel H et al 2000 Effect
of pelvic-floor re-education on duration and degree of
incontinence after radical prostatectomy: a randomised
controlled trial. Lancet 355(9198):98-102
van Kerrebroeck P, Jardin A, Laval KU, van Cangh P 2000
Efficacy and safety of new prolonged release formulation
of alfuzosin 10 mg once daily versus alfuzosin 2.5 mg
thrice daily and placebo in patients with symptomatic
benign prostatic hyperplasia. ALFOTI Study Group.
European Urology 37:306–313
Venn S N, Greenwell T J, Munday A R 2000 The long-term
outcome of artificial urinary sphincters. Journal of Urology
164(3):702–707
Webb V, Simpson R 1997 Older man’s burden. Nursing
Times 93(5):77–80
Wheeler W 1991 A kind of loving? The effect of continence
problems on sexuality. In: Garrett G (ed) Healthy ageing:
some nursing perspectives. Whurr, London, p 144–
149
Wille S, Mills R D, Studer U E 2000 Absence of post void
milking: an additional cause for incontinence after radical
prostatectomy. European Urology 37(6):665–669
Wilson, P D, Berghmans B, Hagen S et al 2005 Adult conservative management. In: Abrams P, Cardozo L, Khoury
S, Wein A (eds) Incontinence, vol 2. Health Publication,
Paris, p 855–964
6/22/2007 10:41:45 AM